Wrong Message - All About Epidural
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Wrong Message

Date: July 13th, 2013

I am sometimes called to give anesthesia for the trial of forceps before caesarean. It is exactly what it sounds like: if the women cannot deliver the baby vaginally and needs a caesarean the obstetrician will give one attempt to deliver the baby with the help of forceps. If it doesn’t work they proceed with the caesarean.

Forceps delivery is quick: when it works the baby is out in a few minutes. It seems to be good, right? The child is delivered, the woman avoided surgery, the obstetrician gives himself the pat on the back and everyone is happy. What doesn’t fit into the picture though is that when forceps delivery is successful the time spent by a woman in the operating theatre is as long (and sometimes even longer) as the time it takes to do caesarean section. How’s that possible?

The answer – perineal tears. There is the reason why a woman cannot deliver vaginally, and forcing the baby through the birth canal inevitably inflicts trauma. The severity of perineal injury depends on a few factors: the degree of the disproportion between the baby’s head and the size of the woman’s pelvis and the vagina, the elasticity of the tissues, the skill and the persistence of the person applying forceps.

Significant tears lead to long-term problems with the pelvic floor. They may include persistent pain, incontinence of flatus (inability to control wind), stool and urine to varying degrees, and painful intercourse.

In comparison with the forceps, caesarean section is a controlled intervention. The technique of the caesarean is standardized, and the degree of trauma from surgery is pretty much the same in every patient. Importantly, the perineum is not affected by the caesarean and pelvic floor is preserved.

Personally, if my daughter asked me if she should choose between the forceps or caesarean if her labor becomes obstructed I would say caesarean. There is statistical data to support this opinion.

The study from the University of Torino in Italy published in 2007 compared the rate of complications after normal vaginal delivery, instrumental delivery and caesarean section performed in the same institution.

According to the mode of delivery the women, all of whom had normal pregnancies, were divided into four groups (number of patients in brackets):

Group 1: instrumental delivery: forceps or vacuum (201)
Group 2: spontaneous (normal) vaginal delivery (402)
Group 3: planned caesarean section (402)
Group 4: emergency caesarean section (402)

Compared with spontaneous deliveries, using forceps increased the risk of maternal complications 6.9 times (3 times for the forceps). Maternal complications were also 3 times higher in the instrumental delivery group compared with emergency caesarean section. The frequency of complications was the same in women delivered spontaneously or via caesarean sections, planned or emergency.

Complications in newborns were also more than three times higher when forceps and vacuum were used, compared with spontaneous deliveries. Complications were also 4.2 times higher in the instrumental delivery group compared with the emergency caesareans. The results of this study speak for themselves: between forceps and caesarean, forceps causes considerably more complications, both in mothers and babies, because it is the most traumatic.

There is another downside to the use of forceps as the last moment action before proceeding to caesarean. The 2007 study from Oxford in the UK found that the trial of forceps before caesarean caused considerable delay in delivery of the baby. It means that even if successful, forceps delivery took two to three times longer than the use of forceps in labor ward. This delay could be damaging for the already hypoxic baby.

For some reason it is accepted by many that successful forceps delivery is somehow fits into the category of the natural birth, while the cesarean does not, even though the former causes more damage to the mother and carries more risks to the newborns than the latter. And this message is carried to the pregnant women.

It would be very satisfying if all labors started and resolved spontaneously. However, for many reasons and in many cases interventions are inevitable. The choice of interventions is made by weighing the risks against the benefits for each particular case. There is no point to pursue some idealistic natural childbirth if it is likely to cause problems in the future. Every issue that relates to childbirth is the subject of polarized opinions. That is why every woman should make up her own opinion about what is best for her, not based on the opinion of midwives, doctors of the media, but on facts.

Undoubtedly, the process of giving birth is important for the woman and her partner. However, it is not as important as the ultimate goal of labor: to deliver a healthy baby and to avoid, or at least minimize, the injury to the mother. These are natural outcomes, and means that help to achieve them qualify as natural childbirth.

Reference.
1. Benedetto C, Marozio L, Prandi G, Roccia A, Blefari S, Fabris C. Short-term maternal and neonatal outcomes by mode of delivery. A case-controlled study. Eur J Obstet Gynecol Reprod Biol. 2007 Nov;135(1):35-40. Epub 2006 Nov 28.

2. Olagundoye V, MacKenzie IZ. The impact of a trial of instrumental delivery in theatre on neonatal outcome. BJOG. 2007 May;114(5):603-8.

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Dr. Eugene Smetannikov is a practicing anesthesiologist with the interest in obstetric anesthesia. He is the author of the most comprehensive book on the subject, The Truth About Labor Epidural

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